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Applications Will Be Processed When Submitted Properly Completed.Be SureToSignTheApplication. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> - - PUMP&WELL <br /> ENVIRONMENTAL HEALTH PERMIT <br /> (COMPLETE IN TRIPLICATE) WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District for apermt onstructand/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordina ce No. 1862 and the rules and regulations of the S n Joa Lin Lo al Health District. <br /> n <br /> Exact Site Address <br /> "X-1 <br /> City/Town CV <br /> r <br /> Owner's Name 1� F Phone 5 <br /> Address City <br /> Contractor's Name Q License# Business Phone Q 5 <br /> Contractor's Address .Z Emergency Phone I <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes !i <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ STRUCTIO r <br /> WELL CHLORINATION ❑ WELL ABANDONMENT 1:1 OTHER ❑ PUMP PUMP REPAIR❑ <br /> REPLACEMENT❑ I <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line Private Domestic WellPublic Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter 11 prod ate Depth <br /> De cribe Materriialan Procedure f fl� '� <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Homeowner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit � <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> I will call f a Grout Ins c'on prior to grouting and a final inspection. 1_ <br /> S— $ <br /> Signed Title: Date: <br /> (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I <br /> Application Accepted By h , P.IrL rak,.ZAAB� <br /> T � �f <br /> Additional Comments: <br /> Phase H Grout Inspection ase,11 n I lnsp tion z; 1A <br /> Inspection Bye — Date Inspection By <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> R (per] <br /> 0 <br /> LESS t <br /> PRORATION ttl <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER �-- <br /> ate Receipt No. Permit No. - Issuance Date Maiied Delivered <br /> -URN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES - 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 <br />